Treatment Acceptability of a Well-Established Cognitive Behavioral Therapy for Panic Disorder in a

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Electronic Theses and Dissertations Fogler Library
12-2004
Treatment Acceptability of a Well-Established
Cognitive Behavioral Therapy for Panic Disorder in
a Passamaqyoddy Community
Elizabeth Ranslow
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Ranslow, Elizabeth, "Treatment Acceptability of a Well-Established Cognitive Behavioral Therapy for Panic Disorder in a
Passamaqyoddy Community" (2004).Electronic Theses and Dissertations. 47.
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TREATMENT ACCEPTABILITY OF A WELLESTABLISHED COGNITIVE
BEHAVIORAL THERAPY FOR PANIC DISORDER
IN A PASSAMAQUODDY COMMUNITY
BY
Elizabeth Ranslow
B.A. The George Washington University, 1993
M.A. University of Maine, 2004
A THESIS
Submitted in Partial Fulfillment of the
Requirements for the Degree of
Doctor of Philosophy
(in Psychology)
The Graduate Schoo-l
The University of Maine
December, 2004
Advisory Committee:
Jeffrey E. Hecker, Professor of Psychology, Dissertation Advisor
Sandra T. Sigmon, Associate Professor of Psychology
Geoffkey L. Thorpe, Professor of Psychology
Linda L. Silka, Professor of Psychology
Maureen E. Smith; Associate Professor of History
TREATMENT ACCEPTABILITY OF A WELL-ESTABLISHED COGNITIVE
BEHAVIORAL THERAPY FOR PANIC DISORDER
IN A PASSAMAQUODDY COMMUNITY
By Elizabeth Ranslow
Thesis Advisor: Dr. Jeffrey E. Hecker
An Abstract of the Thesis Presented
in Partial Fulfillment of the Requirements for the
Degree of Doctor of Philosophy
(in Psychology)
December, 2004
As a step towards evaluating the cross-cultural effectiveness of cognitive
behavioral therapy for panic disorder, treatment acceptability was used in the current
study to gain an understanding of the treatment utility and social validity of that treatment
with a group of Passamaquoddy individuals. American Indian communities face
substantial psychosocial challenges (e-g., poverty, discrimination, and high rates of
violent deaths), which are associated with increased risk for psychopathology, and there
is little empirical evidence of the effectiveness of cognitive behavioral therapy within
these communities.
The current study addressed these issues in two phases. In phase 1, qualitative
methodology was used to develop the culturally-modified treatment description. In phase
2, a quasi-experimental design was used to examine the effect of Passamaquoddy or
European American cultural group on treatment acceptability of the original (CBT) and
culturally-modified (CST) versions of the cognitive behavioral treatment rationale. The
effect of culturally-relevant variables (e.g., mental health values and cultural
identification) on treatment acceptability was also examined.
How a treatment is described affects its acceptability in complex ways,
considering cultural variables, gender, and previous treatment. It was not found that
cultural group had the expected effect, however European American individuals without
previous treatment favored the CST, whereas individuals living in a Passamaquoddy
cultural group with a history of treatment preferred the CST. Within the Passamaquoddy
group, bicultural or European American identifying individuals, compared to the Native
American or marginalized individuals, found both the CBT and CST more acceptable.
The Passamaquoddy group found the CST more acceptable for their community
compared to the CBT, whereas their European American counterparts did not find one
type of treatment more acceptable for their community. Unexpectedly, mental health
values did not affect the relationship between cultural group and treatment acceptability,
and women preferred the CST, while men did not have a preference.
The current study is the first to assess an aspect of social validity and culturally-
relevant factors of a cognitive behavioral intervention for panic disorder in an American
Indian community. In addition, it fills a gap in the literature reporting social validity of
cognitive behavioral interventions more generally.
ACKNOWLEDGEMENTS
I would like to gratefully acknowledge the guidance and encouragement of Dr.
Jeffrey Hecker, who made this dissertation possible. I feel very fortunate to have been a
student under his even-handed mentoring style throughout my graduate career, and will
carry what I have learned from him about research and leadership with me throughout my
career. I am grateful to Dr. Sandra Sigmon, whose excitement over diversity issues, and
creativity in incorporating diversity themes in research, has been inspirational. Over the
years, her sense of humor, personable style, and conviction in me have been saving
graces. I would like to thank Dr. Geoffrey Thorpe for his efforts as a committee member,
and for his kindness as a teacher, clinical supervisor, and friend. I am grateful to Dr.
Maureen Smith, who has privileged me with her insights on mental health issues in
Indian Country, and her encouragement in this project. I would also like to thank Dr.
Linda Silka for her efforts as a committee member. Through the course of this project, I
have come to highly value my relationship with her as a student and fiend.
A special thanks is due to Micah Pawling for his willingness to share his
knowledge of Northeastern American Indian history and his compassionate values during
conversations and drafts. In addition, I am sincerely grateful for the efforts of Diana
Higgins, Wenona Lola, and the research assistants in Dr. Hecker's laboratory who helped
out at various stages. I am grateful to Sheri Stegal for reading the transcripts for
recording. I would also like to thank the .Fah.s-Beck Fund for Research and
Experimentation for their generous financial support.
There is not room to express my gratitude to the all of the members of the
community of Indian Township who hosted a large part of this project. Of note, I would
like to thank the Passarnaquoddy Tribal Council members, Elizabeth Neptune, Roger
Paul, and Judy Lola.
Finally, I am grateful for the support of my family, and other loved ones, who have
been there for me throughout my academic career. I would like to especially thank my
mother for her fountain of love and faith during my graduate training.
TABLE OF CONTENTS
..
ACKNOWLEDGEMENTS. ...........................................................................................
-11
LIST OF TABLES .........................................................................................................i x
LIST OF FIGURES ......................................................................................................... x
INTRODUCTION ..........................................................................................................1
The American Indian and Alaska Native Population .......... .. ............................ 3
Risk and Protective Factors ................................................................................... 4
Psychopathology in Native American Communities ................................................. 8
Depression ....................... .......,... ..........................................................- 9
Alcohol-related Disorders ......................................................................... 11
Anxiety Disorders .................................................................................... 13
Psychotherapy in Native American communities .................................................... 18
NAN History in Psychotherapy ......................... .. .............................. 21
Characteristics of Clinicians ................................................................... 22
Client Characteristics. ............................................................................... 25
Therapeutic Models .................................................................................. 30
Cognitive Behavior Therapy and Native American Clients ....................... 32
. .
Emp~r~calSlyu pported Therapies ........................................................................... 36
Treatment Acceptability ......................................................................................... 43
The Construct of Treatment Acceptability ............................................... 44
The Measurement of Treatment Acceptability .......................................... 47
Overview of Empirical Research regarding Treatment Acceptability ........ 5 1
Research from Child and School Psychology ............................................5 1
Research on Treatment Acceptability for Adult Interventions ................... 54
Culture and Treatment Acceptability ........................................................ 58
Summary ........ '...... .................................................................................................5.8
The Current Project ................................................................................................5 9
Research Hypotheses .............................................................................................6. 0
...................................................................................................................
METHODS 62
Phase 1 : The Focus Group ....................................................................................6..4
. .
Part~c~pan..t.s.. .........................................................................................6. 4
Measures .................................................................................................6. 4
Materials ...............................................................................................6. 5
Procedure .................................................................................................6 5
Analyses ...............................................................................................6. 6
Cultural Modification Process .................................................................. 67
Phase 2: The Quasi-Experimental Procedure ..........................................................6 7
Participants ............................................................................................... 67
Measures ............................................................................................ 6 7
. .
Treatment acceptab~llt.y.. ........................................................ 6 7
Culturally-relevant variables ........................................................7 1
Panic symptoms. ...........................................................................7 4
Materials .................................................................................................. 74
Cognitive behavior therapy rationale ............................................. 74
Culturally sensitive therapy rationale. ........................................... 75
Other materials .......................................................................... 75
Procedure ................................................................................................7. 5
RESULTS ................................................................................................................. 78
Phase 1: Qualitative Analyses: Cultural Modification of a ...................................... 78
Cognitive Behavioral Therapy for Panic Disorder .................................................. 78
The Focus Group Context .........................................................................7 9
Psychological Interventions in General ..................................................... 80
.....................................
Cognitive Behavioral Therapy for Panic Disorder 82
Development of the Modified Treatment Description ............................... 85
Phase 2: The Quasi-Experimental Comparison of a Well-established CBT
and a CST ............................................................................................................ 88
Power Analysis. ........................................................................................8 8
Sample Description .................................................................................. 89
Data Analyses ......................................................................................... 92
Hypotheses ...............................................................................................9 3
Post Hoc Analyses ................................................................................1 00
Dependent measure correlations. ............................................... 101
Community acceptability. ........................................................... 102
. .
Panic hstory ............................................................................... 103
Previous treatment ...................................................................... 104
Gender effects ............................................................................ 109
Mental health values .................................... ...... ......................... 1 10
DISCUSSION ............................................................................................................. 11 1
Phase 1: Creating the Culturally-sensitive Treatment Description ......................... 112
Phase 2: Factors Influencing Treatment Acceptability .......................................... 117
Effects of Cultural Group on Treatment Acceptability .......................... 117
Preference for the CST ...................................................................... 120
Receptivity to unconventional experiences and religiosity. ....... 121
Previous treatment. ...................................................................1 24
Gender and preference for the CST ...........................................1 24
Cultural Identification .................... ...... ..............................................1 26
Community Acceptability ................................................................... 128
Summary .............................................................................................................. 128
Limitations ...........................................................................................................1 30
Conclusion and Future Directions ........................................................................ 132
REFERENCES ........................................................................................................... 136
APPENDICES ............................................................................................................ 170
Appendix A: Criteria for Empirically-Validated Treatments ................................. 170
Appendix B: Focus Group Questions. ................................................................... 172
.......
Appendix C: Transcript of Cognitive Behavioral Therapy for Panic Disorder 174
Appendix D: Outline of Cognitive Behavioral Therapy for Panic Disorder ........... 182
Appendix E: Treatment Evaluation Inventory ....................................................... 187
Appendix F: Semantic Differential Scale .............................................................. 190
Appendix G: Mental Health Values Questionnaire ............................................... 191
Appendix H: Orthogonal Cultural Identification Scale. ....................................... 196